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202207-151699

2022

Fidelis Care New York

Medicaid

Mental Health

Mental Health: Inpatient

Medical necessity

Upheld

Case Summary

Diagnosis: Schizophrenia
Treatment: Inpatient Emergency Admission
The insurer denied: Inpatient Emergency Admission
The denial is upheld.

The patient is an adult female with schizophrenia, diabetes, and hypertension who presented to the hospital with behavioral symptoms/psychosis. The patient was admitted and noted with a creatinine of 1.5 milligrams per deciliter (mg/dl), elevated creatine phosphokinase (CPK) and prolonged QT time.

The patient was started on intravenous fluids, intravenous antibiotics and was admitted to telemetry. The antibiotics were converted to oral and the patient's renal function stabilized to one milligram per deciliter (mg/dl). The inpatient level of care was denied.

No, the proposed inpatient hospital admission was not medically necessary.

The proposed inpatient level of care for the requested dates of service was not medically necessary. Based on Milliman Care Guideline (MCG) 25th edition acute renal failure, there was no documentation of three-fold rise in serum creatinine from baseline, serum creatinine greater than 4.0 milligrams per deciliter (mg/dL) (354 micromoles per liter) with acute rise greater than 0.5 milligrams per deciliter (44.2 micromoles per liter), reduction of more than 75 percent (%) in estimated glomerular filtration rate, or anuria.

There was no documentation of acute kidney injury stage-two or worsening clinical status despite observation care, altered mental status, hemodynamic instability, severe hypertension, cardiac arrhythmias of immediate concern, significant respiratory findings that are severe or persist despite observation care treatment. There was no documentation of clinically significant electrolyte abnormality or metabolic abnormality that is severe or persists despite outpatient or observation care treatment, acute treatment of renal failure (eg, dialysis) not feasible or appropriate in observational care setting, other diagnosis requiring inpatient care, other significant finding or clinical condition judged not to be within scope of observation care.

The requested inpatient stay was not medically necessary as the requested stay would be provided primarily for convenience of the patient or the practitioner, and would not be the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

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